Utilization Review Nurse

PRIMARY PURPOSE: To provide timely, evidence-based utilization review services to maximize quality care and cost-effective outcomes.

ARE YOU AN IDEAL CANDIDATE? We are looking for enthusiastic candidates who thrive in a collaborative environment, who are driven to deliver great work.

ESSENTIAL FUNCTIONS and RESPONSIBILITIES

• Identifies treatment plan request(s) and obtains and analyzes medical records that support the request.
• Clarifies unclear treatment plan requests by contacting the requesting provider’s office.
• Utilizes evidence-based criteria and jurisdictional guidelines to form utilization review determinations.
• Pursues Physician Advisor services when treatment plan requests do not meet evidenced-based criteria.
• Negotiates treatment plan requests with requesting provider when medically appropriate and jurisdictionally allowed.
• Channels certified treatment plan requests to preferred vendors as necessary
• Documents all utilization review outcomes in utilization review software.
• Communicates and works with claim examiners as needed to provide clinical information to resolve issues.
• Maintains a score of 90% or higher on monthly internal utilization review audits.
• Meets productivity goals as outlined by supervisor.

Education & Licensing
Active unrestricted RN license in a state or territory of the United States required. Associate degree from an accredited college or university required.  Bachelor’s degree from an accredited college or university preferred.  Utilization review based certification preferred.

Experience
Four (4) years of related experience or equivalent combination of education and experience required to include two (2) years of recent clinical practice or one (1) year of recent utilization review.

Skills & Knowledge

• Strong clinical practice knowledge
• Knowledge of the insurance industry and claims processing
• Excellent oral and written communication, including presentation skills
• PC literate, including Microsoft Office products
• Analytical and interpretive skills
• Strong organizational skills
• Excellent interpersonal skills
• Excellent negotiation skills
• Ability to work in a team environment
• Ability to meet or exceed Performance Competencies

TAKING CARE OF YOU BY

• Offering a blended work environment.
• Supporting meaningful work that promotes critical thinking and problem solving.
• Providing on-going learning and professional growth opportunities.
• Promoting a strong team environment and a culture of support.
• Recognizing your successes and celebrating your achievements.
• Thrives when everyone is working towards the same vision/goals.
• We offer a diverse and comprehensive benefits package including:
  • Three Medical, and two dental plans to choose from.
  • Tuition reimbursement eligible.
  • 401K plan that matches 50% on every $ you put in up to the first 6% you save.
  • 4 weeks PTO your first full year.

NEXT STEPS

If your application is selected to advance to the next round, a recruiter will be in touch.

As required by law, Sedgwick provides a reasonable range of compensation for roles that may be hired in jurisdictions requiring pay transparency in job postings. Actual compensation is influenced by a wide range of factors including but not limited to skill set, level of experience, and cost of specific location. For the jurisdiction noted in this job posting only, the range of starting pay for this role is $73,000 – $75,000.  A comprehensive benefits package is offered including but not limited to, medical, dental, vision, 401k and matching, PTO, disability and life insurance, employee assistance, flexible spending or health savings account, and other additional voluntary benefits.